Q&A: What are the pros and cons of Alberta's plan for involuntary addiction treatment?
Psychiatrists Rob Tanguay and David Crockford discuss the nuances of making people get help
A potential new law introducing involuntary drug treatment in Alberta would become the first of its kind in the country.
Premier Danielle Smith says the point of the proposed Compassionate Intervention Act is to help severely addicted people who are at risk of hurting themselves or someone else.
Some parents who have watched their child struggle with addiction want involuntary treatment legalized, while critics of the bill question whether it will be effective and what exactly should be done if a person cannot give informed consent to get treated.
LISTEN | Alberta at Noon: Forced drug treatment in Alberta
Psychiatrist Dr. Rob Tanguay is the interim senior medical lead for compassionate intervention with Recovery Alberta and is the doctor overseeing this potential new law for the province. He's also a psychiatrist, teaches at the University of Calgary and he's a clinician who treats people with addictions.
Dr. David Crockford is a clinical professor at the U of C, and is also a practising psychiatrist treating people with addictions.
Tanguay and Crockford joined Alberta at Noon host Ted Henley on Thursday to discuss the nuances of involuntary treatment for addictions.
The following discussion has been edited for length and clarity.
CBC: As an example, [let's say] I am a person who wants to exercise the Compassionate Intervention Act when it becomes law. How would it work?
Dr. Rob Tanguay: First of all, the goal is to access voluntary services. There's areas in this province that significantly lack access points to treatment, there's areas in this province where we have absolute access on demand for individuals.
The first thing that occurs is: an application is submitted, and that application — which is done by an adult family member, a guardian, a health-care professional, police or peace officer — is then reviewed by a statutory director and delegated team. So you know, you can't April Fools your buddy into this kind of program.
The application will be fully reviewed, and then within 72 hours, an assessment will be done to determine if the application and the individual even meet that criteria.
If they are met, a commission member issues an apprehension order and an assessment order. And if not, the application is dismissed and the applicant will be provided with information on alternative care plans.
After the apprehension and conveyance, the police would locate and transport them to the compassionate intervention centre, where they would be assessed. Patients are under the care of a medical treatment team, they will receive full medical support for withdrawal or detox, they will be initiated and receive stabilization, treatment, screening, physical examination, psychiatric examinations — really to determine what's going on for that individual.
That information will be gathered, the statutory director and the delegated team will compile all supporting documentation as well as police records, health records and impact statements. Then there's a commission hearing. This is a three-person commission panel that's independent from the treating team, which will include a lawyer, a physician and a member of the public. They will review everything, they're going to determine if the patient is even eligible.
If they are someone who would require this treatment, they will go into two treatment plans — either a secure care plan, which is up to three months inside of the compassionate intervention centre, or the community care plan which is up to six months in a community-based setting. And then from there goes into aftercare.
The failure of addiction treatment is often no follow-up and we're very aware of that.
Dr. Crockford, what's wrong here then, with the program that's been outlaid by the province?
Dr. David Crockford: There's a few concerns with it. They put out criteria which are attempting to identify the most severe [cases], the criteria are a little bit vague. It's hard to actually spell it out entirely, they're quite broad. It won't be clear for families, health-care providers or police as to who meets the threshold for severity for apprehension.
It's going to require a certain amount of testing and they probably will have to develop an information sheet for people, so that way they get a sense as to who will meet these kinds of thresholds. They're going to be very different. The most severe are probably going to go to a compassionate intervention site.
The problem with that, is that the most severe will tend to have the most treatment-resistant conditions and the highest levels of comorbidities or complexity or other problems — they're gonna have lots of cognitive problems, they're gonna have lots of psychiatric problems, they're gonna have lots of medical problems.
The facility will have to almost function like a forensic facility, there's gonna have to be high observation security because there's gonna be severe aggression risk and potential suicide risk, and then be able to manage complex psychiatric and medical issues in people with addiction. So, the devil's gonna be in the details, I think, with a lot of it.
Another potential concern is, addiction is a chronic disorder. I think Dr. Tanguay spoke about this — people aren't gonna leave compassionate intervention without some sort of a plan, and there needs to be some sort of opiate-agonist therapy if their primary drug of use is an opioid.
The problem is, we don't have a lot of medications for all the other substances. There's some oral medications for alcohol, some oral medications for tobacco, but that's it.
A lot of the problems that we're seeing in the streets right now with aggression and violence is methamphetamine. And there's no evidence-based medications for this, they generally tend to be much more talk therapies, and trying to do talk therapy with a person who's unwilling is kind of like taking a horse to water, right? You can have Evian in there, but the horse isn't going to necessarily drink. So that's gonna be the hard group, in particular, to try and treat.
You have to be a minor under the age of 18, unconscious or mentally incapable of making decisions, that's the criteria where you can give treatment to someone, even if they say no. Can you speak to that Dr. Tanguay? When in an addiction is somebody considered mentally incapable of making a decision for themselves?
RT: That's a complex answer. I mean, look, if they're intoxicated and unwell, there's Step 1. If they're in a frank psychosis — where one of the country's leading experts is Dr. Crockford — that is another one. But when we're talking about somebody whose addiction has taken over absolutely everything in their life, where everything is about getting their next opportunity to not get sick or to get high — in many cases these individuals don't get high anymore, they're just really not getting sick — then we have to really look at, is this person making decisions that someone of so-called sound mind would make?
But, it gets really tricky and complex, and the health-care system does this all the time. People like to think that our Mental Health Act is nice, cut and dry — it's not. A lot of it comes down to the assessment of the psychiatrist in house, the balance of risks and harms of admitting versus discharging, even if they're suicidal or using drugs or unwell, we discharge a lot of people.
And it would be great to admit every single person, but if you come in due to a substance, you will be discharged, and that is a problem. And even if we don't have capacity, we'll just keep you overnight until the substance is worn off a bit, then we'll discharge you, even though everyone around you is saying 'this person is going to die.'
When somebody has regained what we call recovery capital, which is, they've regained all aspects of their life that makes sense, from their social connections to their emotional functioning to their financial capacities, all of these aspects come into play. The last thing this is about is keeping someone under some sort of treatment for the rest of their lives.
Dr. Crockford, what do you see is the biggest risk here, or challenge, of making someone go to receive treatment for their addiction?
DC: I think at the beginning, when a person often lacks capacity, as Dr. Tanguay was describing, when they're acutely intoxicated or when they're in withdrawal, the early stages, the addiction is essentially making the decisions and the person less so. The tricky part is going to be within a few days, few weeks when they are clear and they have the capacity to make decisions.
The legislation is proposing that people can be held either in secure care for three months or bed-based in the community for up to six months. It does get reviewed every six weeks, the care plan, which is good, but you're gonna have a bunch of people who will clear, will say the right thing, because they do have the capacity, but then go back to what they were doing. It's going to be very challenging to balance rights with the need for treatment, and I don't think there's a great answer.
I know people will be going to a commission, and the commission is a lawyer, a person from the public and an addiction medicine physician who will be making treatment decisions or saying where they need to go for treatment. The only problem with that is, that only one of them actually has training, and then you'll have one person's opinion, which might not be the best and there might be more oversight which is required.
It's a very complicated issue, and unfortunately people tend to look at involuntary treatment as being 'OK, we can fix it.' And it's like, well, it's not gonna necessarily fix it, it's a component of care. The treatment of addiction is always to focus on the four pillars, which, enforcement is one of them, which this largely represents. But treatment as well as prevention as well as harm reduction all have to be equally addressed.
Dr. Tanguay, why mandate treatment when we could just improve access to voluntary treatment?
RT: We need both. We are the hub for the community in Calgary, but other cities in Alberta don't have that. And so while here, if you're struggling or you want to talk to someone or you want to talk to someone about your loved one, you can walk in and get support. It may not happen in Lethbridge, it may not happen in Edmonton, it may not happen in Milk River.
Proof of concept has already occurred in Calgary, we've expanded it now to Red Deer. We'll look at seeing it throughout the province. And I agree with everything Dr. Crockford just said about capacity, but we have more than 500 beds coming online in the next two years, brand new beds, eight new recovery facilities to support someone for one year.
We're making it easy for individuals, making it easy for the emergency doctor to refer, making it easy for the family doctor to refer so that we're not just giving people pamphlets and saying 'good luck.'
Imagine showing up to emerge and your chest hurts, and the emerge doc gave you a pamphlet and said, 'there's some cardiologists on there, good luck.' That's how addiction has been treated in this country for many, many decades. Calgary was the first to truly turn this around and we'll see it throughout the province.
Dr. Crockford, just picking up on that 'needing both' notion. Why not have the involuntary treatment option running parallel to the voluntary options out there?
DC: I think it's a component, much like the Mental Health Act for people with severe and persistent mental illness. It does parallel a lot of that. The nice thing about some of the treatments for mental illness is that we do have a little bit more resources and we do have a little bit more treatments that we can provide. Whereas with addiction, often there's limited medications that we can offer, and those medications have their pros and cons.
I don't disagree that there probably is a role for some people. I think the challenge will be in anticipating potential hurdles and troubles that may come with matters, particularly if a person all of a sudden has a very negative experience and they just don't want to seek care. A lot of the people that we see don't have a lot of trust in the health system, don't have a lot of trust in our government. If they feel like their rights are taken away, that'll just be reinforced and they won't accept care thereafter.
Trying to figure out how this involuntary care also applies to community-based programs or non bed-based programs. How you continue to — for lack of a better word — capture those people, because I don't know how it will be implemented. I know they've tried that in different jurisdictions as far as mandating it as part of people's probation and people will tick the box, but it doesn't necessarily alter outcomes.
Again, the devil is in the details of how this is rolled out.
With files from Alberta at Noon